A 45-year-old man presented to us with headache and vomiting for15 years ago. He was diagnosed as having obstructive hydrocephalus due to a pineal region tumour. A ventriculoperitoneal shunt was inserted to relieve hydrocephalus with symptomatic relief. He was followed up with regular MRI scans. Serial imaging showed slow progression in tumor size when he was 60 years old. Neurological examination revealed Parinaud sign with upward gaze palsy. The MRI with gadolinium showed an mildly enhancing lobulated tumor in the region of the superior tectum measuring 22.5mm x 21mm x 20mm (Figs. 1 and 2). The lesion at the superior tectum and the pineal region showed heterogeneous T1-hyperintense signal on precontrast images (Fig. 1). It exhibited very slow growth, with a gradual increase in size over 15 years. There was mild mass effect to the cerebral aqueduct with indentation of the pineal gland (Fig. 3). However, there was no hydrocephalus at that time. In view of symptomatic progression of tumor size, he underwent a near total tumour excision via infratentorial supracerebellar approach.